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4 Ways to Leverage Telehealth to Reduce Rehospitalizations

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Maintaining high standards of healthcare during an unpredictable pandemic has never been so important. Telehealth has continued to be the bridge that allows ongoing care despite the ebbs and flows of COVID-19 and its variants.

Some experts say the pandemic accelerated U.S. digital health by a decade. It quickly became apparent that telehealth in-home health care was no different in evolving with the times. Simply, patients feel safer with fewer people coming to their homes to administer care. 

“We’ve actually known for a long time that telehealth is very helpful in terms of staying in touch with our patients in between physical visits,” says Judy Walsh, Regional Director of Population Health and head of telehealth services at Constellation Health Services. “It had been on our radar to really expand that as an opportunity, even before COVID hit.”

Walsh notes COVID only expedited Constellation’s interest and use of telehealth to complement its Complete Care at Home approach that individualizes treatment for patients in the home setting. The health service company—based in the Northeast—had already begun to transform its approach to telehealth based on data that showed that more patients will enter their senior years in the coming decade, but fewer people are going into the nursing profession. 

Constellation’s solution: Home health telehealth that provides an advanced level of care due to direct access to nurse practitioners (NPs), resulting in reduced COVID exposure and rehospitalizations, lower costs to providers, and better patient outcomes. 

“Our results continue to be positive with both of these Telehealth initiatives. Our Nurse Practitioner video visits and remote patient monitoring (Telemonitoring) programs have consistently resulted in single-digit rehospitalization percentages across our regions from January to June 2021, as compared with the national average of 19.2% overall for this same time period.”

Below, Constellation discusses lessons learned through this new digital era and how providers can leverage telehealth to provide better outcomes.

“Advanced levels of care through telehealth is really the wave of the future.” —Judy Walsh

Reduce Exposure, Hospitalizations with Advanced Level of Oversight 

Telehealth paired with telemonitoring allows home health and other providers to not only check in on patients but assess and address patients’ needs more frequently than through in-person or in-office visits that increase exposure to communicable disease. 

Walsh points out that health service providers have commonly adopted video conferencing or telemonitoring in this new digital health era. They often use these powerful tools for basic check-ins, but Constellation takes it to the next level by directly connecting NPs to all high-risk home health patients through telehealth. The approach to digital health technology has successfully solved problems by detecting COVID symptoms quickly and preventing the likelihood of exacerbations and multiple trips to the emergency room. This advanced level of oversight helps effectively coordinate, communicate, and deliver care throughout the care continuum. 

From COVID symptoms to vital signs trending in the wrong direction, NPs can quickly assess what the patient needs—lab work, a change in medication, mobile diagnostics, or an X-ray. Most care can be managed from home. 

“We found that we were able to manage things that otherwise would have needed to be addressed in an office visit,” Walsh says. “If not for our intervention, these patients would have gone to the emergency room.”

In one case, Constellation’s NP discovered—via a virtual visit—that an individual was experiencing increased pain, weight loss, and advanced dementia with hallucinations. The advanced oversight empowered the care team to quickly respond, allowing the symptoms to be managed from the comfort and safety of home.

Prevent Disease Exacerbations through Telemonitoring

With telemonitoring technology, individuals’ data can be seen by medical professionals in real-time and help them respond expeditiously. However, telemonitoring doesn’t exist in a vacuum. There’s always an element of communication that must be part of holistic care. It comes down to asking questions. 

“If we notice that an individual didn’t take their reading that day,” Walsh says, “we’re going to call them and find out why. Or if that reading is out of range, we’re going to call and find out why and request that they repeat the reading, and make sure they took their medication. 

“There have been a number of scenarios where we’ve picked up a change in the patient that requires further assessment. For example, we found that a patient was having shortness of breath and developing a mild fever. The NP deployed a mobile X-ray and diagnosed that this individual had pneumonia, and we were able to start an antibiotic within hours. We kept that person from getting to a higher level of infection that would have been, of course, much riskier for the patient.”

Empower Patients to Manage Their Long-Term Health

One of the goals of managing care is to teach patients how to self-monitor and utilize the information to prevent disease exacerbations. When there are in-person visits, teaching patients to understand the monitoring device for the long term—what to look for, and when to call if there is an issue—is top of mind. 

“Our job is not only to take care of them,” Walsh says.”It’s to teach them how to manage themselves on an ongoing basis because most times we have diagnoses that aren’t going away and there are potentially a lot of chronic issues that are happening, and we want patients to know how to manage themselves. Our role is to be good teachers, empower patients to have tools, take care of themselves, and continue the success they’ve had with us.

Part of the onboarding and education element of telehealth is to remove the barrier of fear and resistance to using new technologies. The technology is simpler to use than people think. 

“I feel strongly that people need to know that,” Walsh says. “Our training and setup are designed to help the majority of individuals succeed. Answering a video call basically includes touching a screen.”

Collaborate Among Family and Providers

Constellation staff coordinates calls with primary care providers as well as family members and patients. NPs work collaboratively with clinicians, but also with the primary physician so the doctor is always in the loop of what’s happening with their patient. For example, if NPs discover a complication in the home, they will get in touch with the primary doctor at the same time they are talking to the patient, and following up with the family.

Walsh says that Constellation has seen that collaboration through telehealth has improved patient and family experiences for those in hospice. The health services agency implements the technology and other digital tools in unique ways in hospice care for those nearing end of life at home and at skilled nursing facilities. For much of the pandemic, it’s been difficult for family members to visit. Many individuals have been in isolation. 

For the duration of the COVID-19 national emergency, there have been several regulatory changes in the United States to facilitate telemedicine use. One particular change for the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-covered providers is the use of apps that are not fully HIPAA compliant such as FaceTime and Skype. 

The Constellation hospice staff has adopted these tools to connect with family members so they can be “virtually” present with their loved ones when those family members cannot visit. Examples of uses include having virtual birthday parties and memorial services through Zoom, and connecting families through FaceTime as their loved one passes. 

“Because we have adapted our video technology, we’ve supported families in very touching ways,” Walsh says.

Telehealth services are simply great for patients and equally great for providers. With the combination of a visual assessment and the ability to monitor patients through a remote monitoring device, there are also significant savings that go along with that. In healthcare, Walsh says medical professionals are called upon to do two things—take really good care of patients and do it in a cost-effective, efficient manner. When care teams aren’t going to the home, they aren’t incurring costs associated with travel time, mileage, using PPE, etc. 

“I think we really have found something that is going to move us into the future in a stronger position to take care of our chronic and ill patients.” —Judy Walsh


Constellation Health Services is an award-winning, value-based home health care agency serving the Northeast. At Constellation, our goal is to provide a comprehensive stay-at-home health solution for your patients that includes a team of trained professionals, a suite of technology services, and coordination of in-home diagnostic and delivery services. We help partners achieve an average savings of 10% by avoiding rehospitalization penalties and reducing nursing home utilization and length-of-stay. Contact us and learn more.

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